107103
HEARING
BEFORE THE
ON
(II)
CONTENTS
Page
Statements:
Bird, Michael, president, American Public Health Association, Albuquer-
que, NM ......................................................................................................... 6
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, vice chair-
man, Committee on Indian Affairs .............................................................. 1
Culbertson, Kay, executive director, Denver Indian Health and Family
Services, Inc., Denver, CO ............................................................................ 30
Hall, Robert, president, National Council of Urban Indian Health, Wash-
ington, DC ..................................................................................................... 19
Hill, Barry T., director, Natural Resources and Environment, General
Accounting Office, Washington, DC ............................................................ 5
Hunter, Anthony, health director, American Indian Community House,
New York, NY ............................................................................................... 21
Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman, Committee
on Indian Affairs ........................................................................................... 1
Malcolm, Jeffrey, senior evaluator, Natural Resources and Environment,
General Accounting Office, Washington, DC .............................................. 5
Meyers, Carol, executive director, Missoula Indian Center, Missoula, MT . 24
Vanderwagen, William C., acting chief medical officer, Office of the Direc-
tor, Indian Health Service, United States Department of Health and
Human Services, Rockville, MD .................................................................. 2
Waukazoo, Martin, executive director, Native American Health Center,
Oakland, CA .................................................................................................. 26
APPENDIX
Prepared statements:
Bird, Michael (with attachment) ..................................................................... 50
Conrad, Hon. Kent, U.S. Senator from North Dakota .................................. 45
Culbertson, Kay ................................................................................................ 58
Daschle, Hon. Tom, U.S. Senator from South Dakota .................................. 45
Forquera, Ralph, executive director, Seattle Indian Health Board (with
attachments) .................................................................................................. 97
Hall, Robert ....................................................................................................... 75
Hill, Barry T. (with attachments) ................................................................... 65
Hunter, Anthony (with attachments) ............................................................. 87
Meyers, Carol .................................................................................................... 53
Taylor, Jr., Wayne, chairman, Hopi Tribe ...................................................... 61
Valadez, Ramona, executive director, Native Direction, Inc. (with attach-
ments) ............................................................................................................ 139
Vanderwagen, William C. ................................................................................ 48
Waukazoo, Martin ............................................................................................ 56
Additional material submitted for the record:
Magedanz, Tom, staff, South Dakota-Tribal Relations Committee, memo-
randum (with attachments) ......................................................................... 152
Perdue, Karen, commissioner, Department of Health and Social Services,
Alaska ............................................................................................................ 158
(III)
INDIAN HEALTH CARE IMPROVEMENT ACT
U.S. SENATE,
COMMITTEE ON INDIAN AFFAIRS,
Washington, DC.
The committee met, pursuant to notice, at 10:05 a.m. in room
485, Russell Senate Building, Hon. Daniel K. Inouye (chairman of
the committee) presiding.
Present: Senators Inouye, Conrad, and Campbell.
STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM
HAWAII, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The CHAIRMAN. The committee meets this morning to receive tes-
timony on the challenges confronting the Indian Health Service,
privately-administered health care programs, and urban Indian
health care programs with regard to recruiting and retaining
health care professionals today and in the years ahead.
Todays hearing will also address the challenges confronting the
urban Indian health care programs as they address the health care
needs of Indian people residing in urban areasa population which
now represents 60 percent of the total population in Indian coun-
try.
The committee is pleased to welcome the witnesses. We look for-
ward to your testimony.
Before we do, I am pleased to call upon our vice chairman.
STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SEN-
ATOR FROM COLORADO, VICE CHAIRMAN, COMMITTEE ON
INDIAN AFFAIRS
Senator CAMPBELL. Thank you, Mr. Chairman.
In the 106th Congress the committee held four hearings on var-
ious parts of S. 212, and today we will continue with that series
of hearings. This bill would reauthorize the Indian Health Care Im-
provement Act, the core act that authorizes the majority of Indian
health programs.
We have both said many times in the past Mr. Chairman, the
American Indians and Native Alaskans continue to suffer the worst
health status of any group in America. Since 1976 this act has been
a powerful tool in helping tribes and the IHS change the health
status of Native populations for the better. Since the initial pas-
sage of the act, the death rate among the Native population has de-
creased in all categories, and the provision of health services has
(1)
2
that we are the Federal, the tribal, and the urban programs that
are a health system for delivery of health services to Indian people.
As Mr. Campbell noted, significant increases in urban population
are confronting us, in part because cities have now grown to res-
ervation boundaries. Albuquerque can no longer grow north, west,
or south, because they have reached reservation boundaries. And,
in fact, those Indian people who live on those reservations are now
urban Indians in that they live within an SMSA. On the other
hand, the population that was moved in the 1950s and their chil-
dren and grandchildren has expanded significantly, as well. So
there are real issues to address in meeting the health needs of
urban people.
While we talk about health statistics in Indian populations, we
dont have the data we need to fully understand the specific issues
that affect urban Indian people. We have only now, in the last 112
years, established an epidemiology center with a focus on health
needs of urban Indian people. The data needs are large for trying
to understand where the issues are and how we can best address
them, and thats a task that were taking on in consultation with
urban people.
Urban Indians have been included fully in the consultation proc-
ess around budget allocation. They have been included in the budg-
et formulation process. We will continue to include them as active
partners in this health system for Indian people, and we believe
that they are active and viable partners.
I would be remiss if I didnt note that most of those programs,
on average only about one-third of their funding comes through the
Federal sector funded by Indian Health Service. A significant
amount of their funding comes from other Federal programs and
State and county programs, as well. They have been very success-
ful at surviving and expanding their programs. I will give you but
one example.
In Los Angeles County, a 400-square-mile area, the Indian popu-
lation is diffusely scattered throughout that area. The approach
that has been developed is a managed care approach with case
managers, since theres really no focused population of urban peo-
ple, and these case managers work with individual urban people to
identify the best care locations for those people, whether theyre in
the northeast corner of the county or theyre in the southwest cor-
ner of the county, and it has been a very successful program.
Because of unique needs in behavioral health, the State and
county, and particularly the county of Los Angeles, have now
helped that clinic start an active outpatient behavioral health pro-
gram. They just opened it 5 months ago. One-half of the county
commissioners appeared at the opening of this program, and it is
a testimony to the resourcefulness of those Indian people in L.A.
as to the quality of the job that they have been able to do.
There are real challenges, and we appreciate the opportunity to
be here today, and Ill be happy to answer any questions you may
have as the hearing progresses.
Thank you.
The CHAIRMAN. I thank you very much, Doctor.
[Prepared statement of Dr. Vanderwagen appears in appendix.]
The CHAIRMAN. May I now call on Mr. Hill.
5
STATEMENT OF BARRY T. HILL, DIRECTOR, NATURAL RE-
SOURCES AND ENVIRONMENT, GENERAL ACCOUNTING OF-
FICE, WASHINGTON, DC, ACCOMPANIED BY JEFFERY MAL-
COLM, SENIOR ANALYST
Mr. HILL. Thank you, Mr. Chairman. It is certainly a pleasure
for Mr. Malcolm and me to appear before this committee. Were
here today to discuss the issue of Federal tort claims coverage for
tribal contractors, and my comments this morning will focus spe-
cifically on the FTCA coverage and claims history for tribal self-de-
termination contracts at the Indian Health Service.
If I may, Id like to briefly summarize my prepared statement
and submit the full text of my statement for the record.
The CHAIRMAN. Without objection, so ordered.
Mr. HILL. Last year we issued a report to this committee on the
combined FTCA claims history for tribal self-determination con-
tracts at the Indian Health Service [IHS] and the Bureau of Indian
Affairs [BIA]. That report provides more details about the provi-
sions that extended FTCA coverage to tribal contractors and four
emerging legal issues affecting FTCA coverage for those contrac-
tors.
For my testimony today, weve updated the status of the IHS
claims since our report last year, and the figures I will be present-
ing were current as of July 15, 2001.
Let me start my testimony today by briefly describing the process
for implementing FTCA coverage for tribal self-determination con-
tracts.
We are here today because accidents happen, and when those ac-
cidents are caused by the negligent actions of a tribal employee,
the injured parties may be able to seek compensation from the Fed-
eral Government for their personal injuries. For example, if a pa-
tient receives negligent care at a tribal health facility or there is
an accident involving a tribal ambulance, the injured party may be
able to seek compensation from the Federal Government. Federal
regulations implementing FTCA prescribe the process that Federal
agencies must follow in resolving claims arising from the negligent
or wrongful acts of Federal employees. With the extension of FTCA
coverage to tribal contractors, tribal employees or volunteers under
a self-determination contract are considered Federal employees for
the purpose of FTCA coverage.
According to the FTCA regulation, claims are subject first to the
administrative review and determination by the Federal agency
whose actions gave rise to the claim. These claims must be pre-
sented in writing to the agency within two years, and they must
contain a request for a specific amount of compensation.
At the administrative level, claims arising from IHS programs
are filed with the Department of Health and Human Services
Claims Branch in Rockville, MD. The Claims Branch has been del-
egated authority to resolve claims of $10,000 or less, and the De-
partments Office of General Counsel issues administrative deter-
minations for claims in excess of $10,000.
Due to medical malpractice considerations, medical-related
claims go through a much more rigorous review process than non-
medical claims.
6
The CHAIRMAN. For many, many years DOD has been most reluc-
tant to have joint operations with the VA, and, as a result, we have
had VA hospitals and DOD hospitals. But now, with the cold war
over, many of our military hospitals have been destined to be
closed, and in order to keep them open some have become joint op-
erations with the VAfor example, in Hawaii. And the Hawaii op-
eration is a model operation.
Would you consider, where it is feasible, to have DOD have a
joint operation with IHS?
Mr. VANDERWAGEN. I believe that there are opportunities like
thatfor instance, in western Oklahoma. There are other locations
where there may be DOD facilities where, if tribal and urban peo-
ple had effective policy involvement in the development of those re-
lationships, I think we would be very interested in adding DOD
into the partnership.
The CHAIRMAN. Mr. Bird, would that be acceptable to Native
Americans?
Mr. BIRD. Well, I think it is something that one has to approach
very carefully, because I think there is some concern in terms of
most Indian populations that theyre going to end up losing out
when anything like this is explored.
I know in New Mexico, drawing on my 20 years of experience in
the IHS in the Albuquerque area, that there had been initial dis-
cussion back about 10 years ago about negotiating some sort of an
approach with the VA there in Albuquerque, and, as I best recall,
some of the tribes were concerned and actually kind of put a stop
to that because they felt like we wouldthe tribes, in fact, would
be losing out in some form or fashion.
I dont know if that was based on any real threat to the services
that were provided, but I think that there is that perception out
there in the community that somehow it will diminishpossibly di-
minish the Federal Governments role and responsibility to tribes.
But I know that that is a concern.
I think, given the times that we are looking at and the impact,
the adverse impact of lack of services for Indian people and Indian
populations thats occurring today, I think some tribes might be
more open to considering those options.
The CHAIRMAN. We will be thinking about that.
Mr. Vanderwagen, is there any partnering or collaboration be-
tween IHS and non-Federal agencies whenever there is a shortage
of specialties?
Mr. VANDERWAGEN. Yes; Im glad you asked that, because, while
Michael is here representing the Friends and he was unable to sort
of, in his prepared testimony, speak to some of the activities with
themfor instance, the American College of OB/GYN routinely as-
sists us in two ways. One is they will go out with us and do field
site visits to assess the quality of care, needed improvements in pa-
tient safety, protections, medication error management, and that
sort of thing, but they also have a program to provide OB/GYN spe-
cialists to assist us in locations where we have special needs.
The American Dental Association also has done very similar
kinds of site visitation with us and assisted us on a variety of clini-
cal care needs, as well.
10
but after the 6-month period expires the claimant can then go and
file suit in court to get it settled.
Senator CAMPBELL. Whats the longest you would say it takes to
get a claim settled?
Mr. HILL. We found five claims that were filed in fiscal year 1997
that were still pending. That makes them almost 4 years old.
Senator CAMPBELL. Dr. Vanderwagen, you know, there has been
some discussion. In fact, there is a bill in to elevate the IHS direc-
tor to Assistant Secretary in the HHS. Would that be a priority in
the Indian health community?
Dr. VANDERWAGEN. In consultation with the tribes and the urban
folks, that clearly, from their perspective, is a priority to elevate
the director to an Assistant Secretary level.
Senator CAMPBELL. Do you have a personal view on it?
Mr. VANDERWAGEN. I think there are real pluses in terms of the
kind of partnership and access to a wide range of departmental
programs that could be facilitatedfor example, alcohol programs
that cross the Department and other kinds of health programs.
There appears to be some merit in the proposal from that perspec-
tive.
Senator CAMPBELL. There are two demonstration programs, Dr.
Vanderwagen, in Oklahoma that are, as I understand, operated a
little differently from the normal programs in the IHS that I un-
derstand are very successful. How are they different and what
makes them so successful?
Mr. VANDERWAGEN. Well, thank you for asking. Those are inter-
esting and, I think, unique programs.
In the past, Congress provided authority for those programs to
not only be dealt with under title V as urban programs, but to be
dealt with as service units under the Federal process. That means
that they could access resources not only limited to the title V
budget authority but to all the other budget authorities within the
agencyhospitals and clinics, mental health, et cetera.
The plus side of that has been that it has allowed them to ex-
pand and become more comprehensive using IHS funds in address-
ing the health needs of individual urban Indians in Tulsa and
Oklahoma City, and therefore reduce the requirement for them to
seek funding from other sources, to some degree.
Senator CAMPBELL. Theres supposed to be a report made on
those demonstration projects, too, as I understand it. Is that report
finished? Im told it is.
Mr. VANDERWAGEN. Yes, sir.
Senator CAMPBELL. And when are we going to get a copy of that
report.
Mr. VANDERWAGEN. I would have to check on that, but I could
provide you an answer for the record, sir, as to when that would
be available. Im just ignorant at the moment of that.
Senator CAMPBELL. To your knowledge is there any opposition to
launching more programs along the lines of those demonstration
programs?
Mr. VANDERWAGEN. It is a complicated issue with regards to trib-
al sovereignty and the responsibilities and authorities of tribal gov-
ernments vis-a-vis individual Indians who may be in urban settings
and how those programs access resources. This is a real difficult
15
issue, not just involving Oklahoma and Tulsa, but I think all of the
Indian health system at this point, the balance between tribal gov-
ernment and the government-to-government relationship and the
needs of individual Indian people who happen to live in urban set-
tings. Its very difficult.
Senator CAMPBELL. Well, if they have been successful, there is a
good possibility that we could expand that program, then.
Mr. Bird, tell me a little bit more about this. Which organization
participated in this, as you called it, Friends Organization.
Mr. BIRD. Yes.
Senator CAMPBELL. Whats their interest in the Indian health
field?
Mr. BIRD. Well, their interest is in seeing that, in fact, the needs
of American Indian and Alaska Native people are better met, and
there isits a broad coalition, as was mentioned before, of the
American Dental Association, American Association of Colleges of
Nursing, American Hospital Association, American
Senator CAMPBELL. All of them have some health connection?
Mr. BIRD. Yes; all involved in the health arena. I will submit a
copy. I do have a list of the members of Friends of Indian Health.
Senator CAMPBELL. Great. Please submit a copy of that. Well try
to make that a part of the record.
Did you go out and recruit those people to help, or is that some-
thing they put together themselves and volunteered to do?
Mr. BIRD. Its actually something that the American Dental Asso-
ciation put together, has been active for a number of years because
of their interest and their recognition of the fact that theres great
disparity in American Indian and Alaska Native communities.
Senator CAMPBELL. I see.
Mr. BIRD. And they are to be commended because they are a very
active, viable group, and at their behest I am here today.
Senator CAMPBELL. Okay. Swell.
Thank you, Mr. Chairman.
The CHAIRMAN. I thank you very much.
I have a few more questions.
Mr. Vanderwagen, do you have any thoughts on Mr. Birds rec-
ommendation on having Indian volunteers be on the same par as
Peace Corps workers and others?
Mr. VANDERWAGEN. Well, thats a refreshing notion and one that
we have not explored, but it certainly seems to have some merit.
Again, bringing people in, we believe that our mission and the
work that we do is such a blessing in life that if we bring those
people in were likely to keep them for longer than just a simple,
short-term stint.
The CHAIRMAN. Will you have your staff look at Mr. Birds rec-
ommendations and give us your thoughts on this?
Mr. VANDERWAGEN. Yes, sir; I will.
The CHAIRMAN. Are you aware of other federally-sponsored loan
repayment programs that are tax free?
Mr. VANDERWAGEN. I believe that there have been programs
funded through the Health Resources and Services Administration
that has had some tax-free loan repayment components, but I may
be wrong about that, but thats what comes to mind.
16
The CHAIRMAN. Then you do not mind if you are on a level play-
ing field?
Mr. VANDERWAGEN. If wed get back onto a level playing field Id
be real happy.
The CHAIRMAN. Well, Mr. Bird, it appears that you have a few
allies here.
Mr. BIRD. Im glad to hear that.
The CHAIRMAN. Now may I ask Mr. Hill a few questions. Does
the Tort Claims Act provide malpractice coverage for retired pro-
viders who practice on a part-time basis for a contractor?
These questions are asked because I have had letters from In-
dian country.
Mr. MALCOLM. Yes, Mr. Chairman; the Federal regulations that
were issued on thisits 25 CFR, part 900, subpart M talks about
the types of people, both for medical and non-medical claims, that
are covered. It specifically states that temporary employees, if they
are working under a self-determination contract for a tribe, would
have tort claim coverage.
The CHAIRMAN. They are covered?
Mr. MALCOLM. Yes; if they are performing a service under a self-
determination contract.
The CHAIRMAN. Now, does this act also provide coverage for med-
ical specialists, as well as primary care providers?
Mr. MALCOLM. I believe so. Again, depending ona lot of very
legal technical terms apply to this area, and thats why theres a
lot of confusion, and the Department of Justice basically has to
make determinations on a case-by-case basis.
If the specialist, again, is working at the tribal facility, then
clearly there would be that coverage. If that specialist is basically
at a hospital in town thats not a tribal facility, there would be
questions about the coverage in that case.
Again, its the function that is being performed. If its being per-
formed under the tribal contract, there would be coverage either for
full time, part time, or volunteers. When tribal members are get-
ting care from people outside of that contract, then there would be
questions about the coverage.
The CHAIRMAN. Does it make any difference as to the venue of
the care in the tribal hospital or some other hospital?
Mr. MALCOLM. Yes; it would. If that person is not directly work-
ing under the contract, there would bethat would be an issue.
The CHAIRMAN. Mr. Hill, you indicated that volunteers working
at a tribal facility will have tort claim coverage?
Mr. HILL. That is correct, as long as theyre working under a con-
tract.
The CHAIRMAN. Dr. Vanderwagen suggested that, because of this
tort claim issue, volunteers are reluctant to sign up. How are these
claims examined that involve volunteers?
Mr. HILL. I cant answer that. Of the 114 claims that we identi-
fied, none of them involved volunteers, so Im not sure it has been
tested yet.
Mr. VANDERWAGEN. If I may, Senator, its a climate of anxiety
that is not fully assuaged by Justice approach of decision on a case-
by-case basis, and many providers are unwilling to accept the sort
of verbal assurance that, Oh, yes, you will be covered, but we re-
17
The CHAIRMAN. And now may I call upon the second panel: The
president of the National Council of Urban Indian Health, Robert
Hall; the health director of the American Indian Community House
in New York, Anthony Hunter; the executive director of the Mis-
soula Indian Center of Missoula, MT, Carole Meyers; the executive
director of the Native American Health Center, Oakland, CA, Mar-
tin Waukazoo; and the executive director of the Denver Indian
Health and Family Services, Incorporated, of Denver, Kay
Culbertson.
May I call upon President Hall.
reservation and live in an urban area for more than 180 days, they
lose their health coverage through the IHS.
Some of the programs that we provide through our program is
immunization, health promotion and disease prevention, AIDS, al-
cohol and mental health, diabetes, and our chemical dependency
programs.
Missoula Indian Center is governed by a 7-member board of di-
rectors, of which 51 percent must be Native American. Missoula In-
dian Center is organized under two major programs, which is our
health program and our chemical dependency. We have 11 full-time
staff and one part-time mental health counselor.
Health issues that surround our Native American clients range
from diabetes to the common cold. With our agency as a health re-
ferral organization, many of our clients see up to three to five dif-
ferent health providers in the course of a year. With this inconsist-
ency of health providers, there is not a medical health history that
follows our clients as they go to their medical provider. This creates
more confusion and lack of medical knowledge of a clients history.
Many times, because lack of funding, clients will be referred to at
a point of emergency in their situation. There is little prevention
health coverage, such as yearly physicals or dental checkups.
Missoula Indian Centers health program provides quarterly clin-
ics that cover the basic health issues, which in itself is an excellent
program but a significant problem that we are faced with is if a
client comes up with a problem through their medical checkup, we
cannot provide the resources to do the maintenance or followup,
such as when they do a blood screening. If they come back and
there is an issue that they need to do followup with a medical doc-
tor, we basically have to tell them they have to go back to the res-
ervation or seek medical assistance on their own.
It is safe to say that 80 to 90 percent of our clients do not have
health coverage or insurance.
The Missoula Indian Center had 8,865 encounters this past year.
These encounters are community members who accessed the center
for medical issues, drug and alcohol counseling, all the way up to
utilizing the telephone. We are looked upon as a one-stop agency
for many of our needs other than medical.
Other issues besides health issues that our clients face are hous-
ing, employment, school, K12 and higher education, law enforce-
ment, and food.
Presently, we contract with the health agencies such as Partner-
ship Health at a reduced cost for our doctors visits. This enables
health funds to cover more clients over the course of 1 year, but
this does not address the clients need for medical followup or
maintenance, as I discussed earlier.
When a client needs to have a prescription filled, we are able to
transport them to St. Ignatious, which is located on the Flathead
Indian Reservation. This entails a 90-mile round trip. Because of
the Salish and Kootenai tribal policies, clients have to physically
present themselves at the pharmacy in order for their prescription
to be filled. This creates hardship with our clients for two reasons:
No. 1, they may not have a vehicle to transport themselves up; and,
No. 2, they may not have gas to put in their vehicle to make the
90-mile round trip.
26
Other services that we seek for our clients to try to utilize on the
Flathead Reservation is the dental clinic, but in order for a client
to be seen they have to leave the Missoula area at 7 in the morning
to be there at 8 a.m. to be seen in an emergency dental situation.
Once again, for them to utilize it, it is an emergency, either a
toothache or some type of infection. Theres no or little prevention
for our dental.
In our chemical dependency programs we offer intensive out-
patient and standard outpatient groups and some individual coun-
seling. Our programs are Montana State certified, so were able to
see non-Native American clients, which we do some billing with
that particular population.
Our programs are spiritually and culturally themed, and many
of the agencies other than our programs that provide counseling
make comment that the uniqueness of the counseling sessions do
help with the holistic approach with recovery of the addiction, and
they have been noted for this in the State of Montana.
When clients come in to utilize these alcohol programs, they not
only bring their addiction but they bring many, many health prob-
lems, and we are seeing more diabetics in this course of our target
population in this area.
I want to just interject this personal note. My father who is 82
years old has been a diabetic since the mid 1970s. My mother is
79 years old and she has been diagnosed with diabetes for the last
15 years. My father is a World War II veteran, has been an ad-
mirer of yourself, Senator Inouye, and this Commission for many
years and thinks of you as a champion on issues that pertain to
the American Indian. He has made comment that he would like to
leave the reservation, but because of the lack of health coverage in
the urban areas he is unable to leave the hospital in Browning,
Montana, because that is his life support for he and my mother.
I want to thank you for your time for listening and reading my
testimony. It has been a privilege and an honor to come before you
with my thoughts and ideas. Each and every day Native Americans
are faced with issues and problems of health, employment, and
education. I sincerely hope with my testimony that our issues have
been personalized. Survival on a day-to-day basis for Native Amer-
ican people is a very real issue.
Thank you.
The CHAIRMAN. Thank you very much, Ms. Meyers.
[Prepared statement of Ms. Meyers appears in appendix.]
The CHAIRMAN. May I now recognize Mr. Waukazoo.
STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR,
NATIVE AMERICAN HEALTH CENTER, OAKLAND, CA
Mr. WAUKAZOO. Thank you, Mr. Chairman and Mr. Vice Chair-
man. My name is Marty Waukazoo, and I am an enrolled member
of the Rosebud Sioux Tribe in South Dakota. I was born and raised
in South Dakota. I moved to California in 1973 and have been the
executive director of the Urban Indian Health Board since 1982.
My wife and I have three children and two grandchildren. My wife,
Helen, is the executive director of the Friendship House Associa-
tion of American Indians in San Francisco, which is an alcohol an
drug rehabilitation center partially funded by the IHS.
27
Last year our medical clinic saw over 4,800 patients, with over
16,800 visits. Of our patients, 98 percent meet the Federal poverty
level guidelines.
The services we provide reflect our communitys expanded defini-
tion of healththat health of an individual depends upon the
health of the community. If we have a healthy community, well
have healthy individuals within our community.
I would like to outline some of the critical issues facing our clin-
ics todayissues that ultimately impact the health of our commu-
nity in the Bay area.
Back in 1985 we bought a building in east Oakland, a four-story,
20,000-square-foot building. We bought that building at a time
when the market was very low. Today, we have filled up that build-
ingfour floors offering comprehensive services. Again, we also
have set up a fitness center, a gym on the first floor as part of our
preventive efforts.
The issues of providing health care has increased significantly
over the years. Pharmacy costs for us have increased by 34 percent
from fiscal year 1999 to fiscal year 2000. According to our medical
director, 20 percent of our medical users are diabetic20 percent
of our medical users are diabetic. A diabetic with high sugar, high
cholesterol, and high blood pressure, a very common combination,
can average $3,000 per year in drug costs. Just 40 such patients
for a clinic like ours can cost us $120,000 a year, or close to 13 per-
cent of the total IHS funding that we do receive.
Capital needs for our clinic have been and continue to be a major
issue for us. We have been located at 56 Julian Avenue since 1972.
We lost that lease this year. Our lease rent at the 56 Julian site
was $6,500 last year [sic]. We moved to a new location a 112blocks
down on Cap Street. Our rent has increased to $20,000 a year
a month. From $6,500 to $20,000 a month. The market has gone
up and exploded in the urban areas.
We are currently at full or near capacity in our medical clinics
and our dental clinics. Poor design, inefficient and inadequate tech-
nology has also been an issue that we have to struggle with. Weve
had to obtain additional funding from within private foundations
and corporations in order to buy the needed computer equipment
to at least continue to participate in the local health care delivery
system in Alameda County and in San Francisco.
Health insurance premiums for employeeswe have 120 employ-
ees. Our health insurance premiums have increased by 28 percent
in the last 3 years.
The California energy crisis is also having a major impact on us.
These costs have increased by 40 percent over previous years.
Another critical issue thats going to impact our ability to provide
primary care in the next year or two is something very positive in
our community. The Friendship House Association of American In-
dians will be building an 80-bed alcohol and drug treatment center
in San Francisco. Through a partnership with the city of San Fran-
cisco, they were able to obtain funding to buy property in the Mis-
sion District to build this 80-bed facility. That is great. There is a
need there. That 80-bed facility is going to become a regional treat-
ment center for not only California but for the western United
States.
29
Another thing is that they expect certain things from the urban
Indian health programs, and a lot of times they expect us to func-
tion like IHS facilities or tribal facilities with the limited funding
that we have. My operating budget is only about $400,000, so try-
ing to provide all the things that IHS provides, requires is some-
times overwhelming, and so I think that there needs to be some
sort of different look at how the urban programs can get their fund-
ing increased, get some of the benefits the tribes have, and also
provide some support for us.
The CHAIRMAN. Montana?
Ms. MEYERS. I would like to see a more workable relationship
with IHS. I grew up with IHS, and I would like to see, as an urban
settingand I put it on a personal note. Ive tried to convince my
parents to come live with me in Missoula, but because of the lim-
ited health coverage that they would receive in Missoula their
hands are tied. They would love to come and spend time with me
and live in an area that they enjoy, but because of the lack of cov-
erage of their medical needs it is totally impossible.
The CHAIRMAN. The first panel spent some time discussing tort
claims, malpractice. Is that a matter of major concern to the urban
Indian health centers?
Mr. HALL. If we fully participated under that protection, it would
save each one of us high malpractice insurance costs. We all have
to maintain high liability once we start providing direct service for
that. Again, its because of the authority. Because were not 638, it
doesnt apply to a buy-Indian provider, so technically right now, ac-
cording to what is legislated, we wouldnt be able to participate in
it. There would have to be some enabling legislation that would
allow us to be covered by that.
The CHAIRMAN. What is the cost of insurance in Denver?
Ms. CULBERTSON. Well, for us our insurance is running about
$800 a year, but we have a very good relationship with a nonprofit
group that provides the malpractice insurance for us. And because
we have such limited services, our malpractice insurance isnt as
high.
If we opened up our doors to OB, to prenatal care, our costs
would skyrocket and we wouldnt be able to afford those services.
So the malpractice really determines on what you offer, and
probably the best guess is Martys malpractice, because they are a
comprehensive center and are probably the closest to what an IHS
facility would be, how much their malpractice insurance costs.
The CHAIRMAN. How is it in Oakland?
Mr. WAUKAZOO. I dont have that figure in front of me right now.
The CHAIRMAN. Any figures from Montana?
Ms. MEYERS. Because we are a health outreach referral, we con-
sidered and looked at when we do become a clinicand thats one
of our goals, to become a clinic for our area. That is one issue that
has been discussed among staff and our board of directors is the
cost of malpractice insurance, which if we dont come under this
claim, the Tort Claims Act, then we will be looking at high insur-
ance in that area.
The CHAIRMAN. Anything in New York?
Mr. HUNTER. Very similar situation in New York, sir. We are an
outreach and referral. We do direct counseling services, and on oc-
38
casion some of our counselors in the past have insisted that there
be coverage provided. We dont have it in our budgets, and so
theyve had to purchase their own malpractice insurance.
The CHAIRMAN. Mr. Hunter, I would gather that most of your
beneficiaries are from outside New York?
Mr. HUNTER. Yes; a large segment of the population is Mohawk
from the two reservations in upstate New York. A large population
is from eastern Long Island from Shinnecock and the Unkechaug
Reservation. Shinnecock is about 90 miles east. Thats where my
family is. And Cherokee people are also a large number. In our De-
partment of Labor statistics, I just noticed in reviewing those that
Navajo is also well represented in New York City.
The CHAIRMAN. And for Montana the population is from that
area?
Ms. MEYERS. The biggest population that we serve are the Black-
feet, and it goes on down to the Flathead, which is Salish and
Kootenai, Asinniboine. All the 11 tribes that live in the State of
Montana do come to the Missoula area, plus nationwide we have
Navajos from the southwest, Apache that do come up to attend the
University of Montana, and we have a variety.
The CHAIRMAN. How is it in Oakland?
Mr. WAUKAZOO. The largest group of tribes that we provide serv-
ice for are the California tribes. Individually largest group is the
Navajo, Lakota, Pomo, Cherokee, Apache, Paiute, Blackfeet, Choc-
taw, and Chippewa, in that order.
The CHAIRMAN. Denver?
Ms. CULBERTSON. Well, as I said before, 64 percent of the people
we see are from the Sioux tribes, and then 30 percent are Navajo,
and then it is a whole mixture. The one tribe we rarely, rarely see
are the Southern Utes and the people from our home State.
The CHAIRMAN. Well, I thank you.
May I now call upon the vice chairman.
Senator CAMPBELL. Thank you, Mr. Chairman. We have a con-
ference in another 15 minutes or so, so Im going to submit most
of my questions in writing, if thats acceptable.
I might just ask Kay, does Rosalie Tall Bull work with you?
Ms. CULBERTSON. No; Gloria works for me. Shes my community
health specialist. But Rosalie works for National Indian Health
Board.
Senator CAMPBELL. Okay. Shes my sister. I dont know if you
knew that.
Ms. CULBERTSON. Yes; I knew.
Senator CAMPBELL. Tell her hello for me. You see her more than
I do.
Ms. CULBERTSON. Ive got alot of friends that know you.
Senator CAMPBELL. Yes; alot of relatives.
Carol, does Henrietta Whiteman still run the Native American
studies program up there at Missoula?
Ms. MEYERS. No; unfortunately, Bozeman got her.
Senator CAMPBELL. Bozeman? Oh.
Ms. MEYERS. And so shes down in the Bozeman area at MSU.
Senator CAMPBELL. I see. Well, shes not my sister. Shes my
cousin.
Ms. MEYERS. Okay. Thats good.
39
Senator CAMPBELL. You can tell her hello if you see her, too. I
dont have any relatives in anybody elses area thats testifying, but
they brought up some really interesting questions, Mr. Chairman.
Im probably not going to get into them. We just wont have the
time.
But Mr. Waukazoo really I thought alluded to something really
important, and that is that when you talk about Indian healing its
just not a matter of giving them pills and Band-Aids. Its a form
of holistic healing. So much of Indian healing has to do with their
spiritual feeling and their cultural feeling about being in balance
with their surroundings and so on.
I think that when you talk about all the activities you have in
your center, your health center, and Mr. Hunters too, in New York,
superficially you might say, Well, what do those have to do with
health? But they have a lot to do with health with Indians, and
I think they are really worth pursuing and worth expanding, too,
if you can do this.
Obviously theres a question of how to finance all those things,
and thats what I wanted to ask you. You must have a pretty large
staff to do all those different activities you do. Is that all done with
donations and volunteerism?
Mr. WAUKAZOO. Its done with a lot of dedication and commit-
ment on the part of the staff. And I agree with you 100 percent
about health careits much more than just providing health care
externally in the western model.
You know, when I was growing up in South Dakota my parents
used to tell me, Get out of the house. Go out and play. Today par-
ents are saying, Stay in the house.
Senator CAMPBELL. Yes; youll get sick.
Mr. WAUKAZOO. Dont go outside. So now we have a generation
who is growing up. I coach the Grasshoppers. We have a tribal ath-
letic program, part of our clinic. The Grasshoppers are first and
second graders, little guys. I coach them. We havent won a game
in 2 years, but thats not important. [Laughter.]
Senator CAMPBELL. Youre developing character.
Mr. WAUKAZOO. Whats very important is that theyre out there
getting active and theyre learning that theyre at risk for diabetes.
But they cant even run up and down the court three or four times
without getting tired. We get ahead by two or three points at the
end of the first quarter but we loose by the end of the game be-
cause theyre all tired.
How do we do it with financing? Well, health care is local. We
spend a lot of time and a lot of energy at the local level. The local
level and the State and the county delivery system have a respon-
sibility also.
Our greatest concern is were seeing a larger and larger group of
those uninsured, those individuals that are not eligible for Medi-
care, Medicaid, Medical in our State.
Then we also look in that other option in partnering up with dif-
ferent other organizations. We will be building a youth develop-
ment center in the next year which will incorporate a gymnasium,
performing arts studio, fitness center, and its really about the next
generation because thats our largest population. If we can get in
front of this diabetes and these other health problems, you know,
40
His wife says, Im not. And theyve got a couple of kids with
them. Do you say, Well, we can help you but not her? How do
you deal with that?
Mr. WAUKAZOO. Thats whats in the family.
Senator CAMPBELL. Okay. So if he identifies, his whole family
then is
Mr. WAUKAZOO. Yes; the communityyou know, in the Bay
areain urban areas the community is spread out but it is very
highly connected. Its well known. Its just like on the reservation.
You know who is on the reservation.
Senator CAMPBELL. You generally know because youve seen
them at activities
Mr. WAUKAZOO. Yes.
Senator CAMPBELL [continuing]. And they participate in the com-
munity.
Mr. WAUKAZOO. Yes; right.
Senator CAMPBELL. I see.
Mr. WAUKAZOO. And that decision generally is within the family
as far as where the health care is going to be taken care of, so we
dont get into that part of it.
Senator CAMPBELL. I see.
I think, in the essence of time, Mr. Chairman, Ill submit the rest
of my questions in writing, if I could ask the panel to respond.
Thank you, Mr. Chairman.
The CHAIRMAN. I will also join you in submitting questions, if I
may.
A final question. In the Native Hawaiian Health Improvement
Act, there is a provision for traditional Native healers and tradi-
tional Native Hawaiian healers are officially recognized by the Gov-
ernment of the United States. They are compensated for their serv-
ices.
Are Native American Indians interested in having this act pro-
vide for traditional Native healers? I do not want to tell you what
to do, because I believe in you telling us what to do.
Mr. HALL. I just came from the Aberdeen Area Tribal Chairmans
Health Board meeting, where they spoke of this very issue. They
had a healer from the Navajo Reservation that is part of the
Shiprock, I believeno, excuse me, Winslow service unit. Some of
the requirements you have to go through to become billable under
Medicaid are so stringent that most of the healers feel they are
stepping outside of their cultural powers to participate in that, so
most of them, as it is now structured, are not reimbursable.
From the conversation of the Navajo people and from the Lakota
people and others up in the Aberdeen area, if that provision youre
describing could be applied without having to do all of the hoops,
theyd very much appreciate it.
IHS, as a whole, is being very receptive to utilizing traditional
healers, and I think the tribes, but we dont all speak for the tribes.
I can only speak from that experience.
The CHAIRMAN. Any objections?
Mr. WAUKAZOO. I would just say that it would be a decision that
I would prefer to have the tribes make, and if the decision is yes,
then we would be very supportive. But, you know, sometimes we
have to, in urban programs, kind of step back and follow the tribes.
43
PREPARED STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA
Mr. Chairman, thank you for holding todays hearing on the personnel and urban
Indian provisions of the Indian Health Care Improvement Act.
Senator Dorgan and I chaired a field hearing last August in North Dakota to con-
sider this legislation. I can attest to the fact that tribes in my State believe changes
need to be made to the way health care is delivered throughout Indian country.
This bill is one of the most important pieces of legislation being considered by this
committee. Tribes in North Dakota have told me time and again that health care
is their top priority. Without healthy people, all other endeavors will be less success-
ful.
I am pleased that the committee has worked so closely with tribes in putting to-
gether this important bill. I hope we are nearly to the point where we can pass this
legislation and allow health care improvements to move forward throughout Indian
country.
This is especially important for the growing number of young Native Americans.
We need a greater emphasis on prevention of disease and injury overall, but espe-
cially with respect to young people. Wellness and nutrition training, teaching young
people to stay away from drugs, tobacco, and alcohol, and greater attention to the
mental well-being of young people are all goals that I believe we should embrace.
Greater access to medical care, both rural and urban, and more health care person-
nel throughout the system are vital to reaching those goals.
Mr. Chairman, thank you for holding this hearing today.
PREPARED STATEMENT OF HON. TOM DASCHLE, U.S. SENATOR FROM SOUTH DAKOTA
Mr. Chairman, thank you for the opportunity to testify on one of the most impor-
tant issues before this committeeour commitment to provide quality health care
for American Indians and Alaska Natives. As you know, the Indian Health Service
[IHS] is in far too many cases unable to provide even basic health services to Amer-
ican Indians and Alaska Natives. We are failing to uphold a promise we made many
years ago in Federal-tribal treaties as well as Federal statute.
The IHS is tasked with providing full health coverage and care for American Indi-
ans and Alaska Natives, but is so underfunded that patients are routinely denied
care that most of us take for granted and, in many cases, call essential. The budget
for clinical services is so inadequate that Indian patients are frequently subjected
to a life or limb test. Unless their condition is life-threatening or they risk losing
a limb, their treatment is deferred for higher priority cases; by the time they become
a priority, there are often no funds left to pay for the treatment.
As devastating as the problem is for Native American patients and the tribal gov-
ernments struggling to address their peoples health needs, the problem does not
end there. IHS often contracts with non-IHS facilities to provide care that cannot
be provided at local IHS clinics and hospitals, due either to the complicated nature
(45)
46
of the needed service or a lack of funds. These non-IHS facilities often receive no
reimbursement for the services they provide and, as a result, face serious budget
shortfalls of their own. In 1999 alone, IHS issued 20,000 contract health service de-
nials, leaving the contract facilities without any reimbursement.
A compelling example of the impact of this underfunding is the inability of many
tribes to provide emergency medical services [EMS] to their residents. IHS uses its
authority through the Indian Self-Determination and Education Assistance Act of
1975 to contract EMS to tribes. Throughout Indian country, however, ambulance
service is funded at only 47 percent of the determined need. On the Rosebud Res-
ervation in South Dakota, the funding for EMS is depleted by mid-year. The Rose-
bud Sioux Tribes EMS contractors respond to 425 calls per month. The local IHS
facility does not have an obstetrical or surgical unit, so all high-risk pregnancies
and surgeries have to be transferred by the EMS providers to private hospitals lo-
cated 180 to 260 miles from the reservation. When the tribes funds for EMS are
depleted, other local providers are often called to respond to emergency transport
needs. Consequently, local EMS providers experience serious financial difficulties
because there are no funds left to reimburse them. Ultimately, this situation can
result in discontinuation of ambulance services in a rural area.
I attempted to address the crisis created by this serious, chronic underfunding of
IHS by offering an amendment to the fiscal year 2002 budget resolution. The
amendment called for a $4.2-billion increase for the fiscal year 2002 clinical services
budget of the IHS. This amendment passed the Senate, but was not included in the
bill that returned from conference. I again attempted to address this situation in
the Interior Appropriations bill, but it appears that we will be unable to do that
at this time due to the inadequate budget allocation facing the Interior Appropria-
tions Subcommittee.
It seems Congress has grown so accustomed to inadequate IHS funding that we
are failing to recognize the extraordinary tragedy tribal people are facing. The prob-
lem seems so big that we are almost afraid to tackle it. But we cannot afford to
shirk our responsibility.
One reason the problem seems so intractable is that IHS fundingand, in turn,
health care for Native Americansdepends on the vicissitudes of the appropriations
process. The budget for IHS has been so underfunded for so long, our annual appro-
priations process may never allow us to increase it enough to adequately address
the health needs of American Indians and Alaska Natives. The magnitude of the
increase I requested is evidence of this point: For fiscal year 2002, I requested a
$4.2-billion increase to the $1.8 billion budgeted for IHS clinical services. This 233
percent increase is based on two conservative estimates of the amount needed to
adequately fund the provision of basic clinical services: The tribal needs budget and
the level of need funding budget, developed by the tribes and IHS respectively.
It is time to change the way we fund our commitment to provide health services
to American Indians and Alaska Natives. This Federal responsibility was codified
by treaties and laws dating from 1787 and required under the trust responsibility
of the United States to the tribes. It is clear that, in a historic and moral context,
American Indians and Alaska Natives are entitled to receive adequate health serv-
ices from the Federal Government. Why then, are they not getting it?
What some may not know is that health care for Indians is not delivered as an
entitlement. I have come to believe it is time to consider changing the funding
mechanism for IHS from a domestic discretionary program to an entitlement. Un-
less we can demonstrate a renewed commitment to Indian health care in the budget
and appropriations process, granting entitlement status may be the only way we
will live up to our obligation. I understand the political challenges that this entails.
For Indian people, however, this is not a. question of politics. It is a question of his-
tory and obligation. It is a question of health and life.
If Indian health were moved from a domestic discretionary program to an entitle-
ment program, it would no longer shoulder the burden of balancing the Nations
budget, along with other discretionary programs. We would have to develop a new
process to quantify Indian health based on services and beneficiaries. Funding
would be guaranteed.
I wholeheartedly support, therefore, the provision in the Indian Health Care Im-
provement Act which establishes a National Bipartisan Commission on Indian
Health Care Entitlement. I look forward to the Commissions report, and to continu-
ing the discussion of this critical issue.
I would like to bring to your attention another critical issue impacting IHSs abil-
ity to provide health care services. The IHS experiences enormous difficulties in re-
cruiting and retaining health professionals. In 1999, in the Sisseton Indian Health
Service unit, there were 34 different physicians providing medical care in four fund-
ed provider positions. This high turnover rate significantly erodes the IHSs ability
47
to provide high quality health care services and continuity of care. We must address
this issue because, without health care professionals, health care services cannot be
delivered.
The Sicangu Sioux on the Rosebud Indian Reservation in South Dakota recently
built a beautiful new hospital and health care center. While in many ways they are
equipped to provide state-of-the-art care, they are unable to retain health care pro-
fessionals. As a result, their brand new delivery and surgery rooms stand empty,
and individuals living on the reservation are forced to travel long distances to re-
ceive these vital services.
There are many documented reasons for the difficulty recruiting and retaining
IHS health professionals, including low pay, lack of suitable housing, isolation, and
an overwhelming workload. Some health care professionals do not want to practice
long-term in chronically underfunded, crowded and outdated facilities that lack es-
sential equipment. I am pleased that S. 212 includes an array of excellent programs
to improve the ability of the IHS to recruit and retain health care professionals.
There is, however, one issue that is not addressed in S. 212: Medical license reci-
procity for HIS physicians.
IHS physicians, as a condition of employment, must hold a license in at lease one
State. Since they are Federal employees, this license should guarantee their ability
to work as an IHS physician in any State. This concept is called reciprocity. In
South Dakota, IHS physicians are granted reciprocity and allowed to practice under
a license issued from a different State. Their scope of practice, however, is limited;
they are not allowed to practice outside of an IHS facility. This limitation is ex-
tremely frustrating, since, due to severe underfunding of the IHS, many areas do
not have IHS facilities, such as hospitals, nursing homes, or specialized clinics.
Many physicians prefer to follow their patients throughout the systems of care. If
an IHS patient is transferred from an IHS facility to a non-IHS facility for inpatient
care, for example, the IHS physician is currently forced to turn over the care to a
non-IHS physician, who may not even know the patient.
Given the many challenges IHS faces in recruiting physicians, I firmly believe we
should not create another barrier. The inability of IHS physicians to practice outside
the bricks and mortar of an IHS facility has led to the resignation of too many IHS
physicians. I hope we can find a way to remove this barrier as we move forward
with S. 212.
I was pleased to see that S. 212 continues an emphasis on programs to com-
prehensively address substance abuse and Fetal Alcohol Syndrome [FAS]. According
to IHS, the 199495 age adjusted death rate for alcoholism in the IHS Service Area
was more than six times that of the general population. Yet, treatment services for
Native Americans remain severely inadequate.
Programs to address FAS are particularly crucial. FAS is the leading preventable
cause of mental retardation in the United States and the No. 1 cause of preventable
birth defects. Although the exact prevalence of this disorder is unknown, studies
have estimated that 3 out of 1,000 Native American children are born with FAS,
and many more with less severe alcohol-related impairments.
These statistics highlight the urgent need for increased access to residential treat-
ment services for women of childbearing age. In the Pine Ridge area of South Da-
kota, there is currently a five-month wait for IHS residential substance abuse treat-
ment programs. This means that if an alcoholic woman learns she is pregnant and
is motivated enough to request treatment, she would probably be more than 6
months into her pregnancy before a bed was available. By this time, her unborn
child could be severely and permanently damaged.
We need to ensure that when a pregnant woman walks in the door to ask for help
with her drinking, help is available. In addition, we need to do all we can to educate
Native American women, as well as professionals who serve the Native American
community [as well as the non-Native community], about FAS and the dangers of
drinking while pregnant. And we need to ensure that when these approaches have
failed and a child is born with FAS, that child has access to the medical, edu-
cational, and social services he or she needs.
In closing, I would like to thank the chairman, the vice chairman and the entire
committee for their dedication to improving the health of American Indians and
Alaska Natives. S. 212 is a comprehensive reauthorization of the Indian Health
Care Improvement Act, and, when enacted and if adequately funded, will go a long
way toward reducing the disparities in health outcomes between Native and other
Americans. It saddens me to know that the mortality rate for American Indians and
Alaska Natives is higher than for all races in the United States, and life expectancy
is the lowest. I commend you for your efforts to eliminate these disparities and live
up to our commitment to provide health services to American Indians and Alaska
Natives.
48
PREPARED STATEMENT OF DR. WILLIAM C. VANDERWAGEN, ACTING CHIEF MEDICAL
OFFICER, INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Good morning, Mr. Chairman and members of the committee. I am Dr. William
C. Vanderwagen, acting chief medical officer, Indian Health Service [IHS], Depart-
ment of Health and Human Services.
I am pleased to be here this morning to testify before the Senate Indian Affairs
Committee about two important areas within the IHS service responsibilities.
The first issue of health manpower, providing and retaining sufficient health pro-
fessionals for our health care delivery system, is one shared by the country overall.
The second matter concerns the operation and challenges facing the urban Indian
health programs.
In meeting our goals, the IHS has adhered to its policy of working with our tribal
and urban partners and constituents, on key decisions and actions. Efforts to im-
prove program delivery of services are greatly improved by such consultation and
cooperation.
The IHS health care delivery system is comprised of 49 hospitals, 219 health cen-
ters, 7 school health centers and 293 health stations. The American Indian and
Alaska Native eligible population, in fiscal year 2000 was approximately 1.51 mil-
lion. This service population is increasing at a rate of about 23 percent per year,
and this estimate excludes the effect of the additions of new tribes. *[Trends 1998
99]
Patient admissions into our IRS, tribal and contract general hospitals, in fiscal
year 1997, were about 85,000. Main causes for admission were births and pregnancy
complications. The 2 ambulatory statistics in fiscal year 1997 show over 7.3 million
medical visits provided through the IHS-funded operations.
There, are additional data to be found in our IHS 199899 Trends publication,
but the main purpose of this review is to provide the backdrop against which much
of our discussions will take place this morning.
It is to the credit of our personnel, health professionals and others, that all of our
IHS and tribally operated health facilities had achieved accreditation by the Joint
Commission on Accreditation of Health Care, Organizations [JCAHCO]. This rating
was true as of January 20, 1999.
To fulfill our primary goal of ensuring that we achieve the highest possible health
status among American Indians and Alaska Natives, the health professions activi-
ties are critical but could be tested over the next 5 years. The IHS could lose a sub-
stantial number of its staff for a variety of reasons, including age-eligible retirement
and the fulfillment of service obligations.
As of the end of June 2001, nearly 22 percent of our 13,000 Federal employees,
throughout the whole system, had 20 or more years of service. Within the health
professions, 18 percent of the 8,600 health-related employees in the 600 personnel
series, in which most of the health professionals are found, are in the 20-plus years
category. Finally, of the three most numerous health professions, nurses, phar-
macists, and dentists, all of these groups have more than 12 percent of their staffs
in this group age-eligible retirement category. Physicians have 8 percent of all of
our IHS physicians are in the 20-plus years category.
Our plans for addressing this pending situation include the institution of even
more vigorous recruitment efforts and a greatly increased emphasis on retention.
Such activities include:
1. Increased advertising in professional journals.
2. Increased Health Educational Institution Recruitment Visits.
3. Increased web-based Advertising.
Retention has been a major factor in reaching our current status. The average
length of service for all IHS employees is just over 12 years. For those in the 600
series, it is just over 11 years.
Of our four most numerous professions, nurses have the longest average length
of service, at nearly 11 years. Physicians, with 8 years, have the shortest, while den-
tists and pharmacists average just over 9 years each. The difficulty, however, is that
we lose many of our new recruits before they have served 5 years. Therefore, reten-
tion of new employees must remain a priority.
These difficulties in retention include culture and transition issues, within rural
and often disadvantaged communities. Additionally, the competition for such quali-
fied individuals is huge. Many of these professionals are often approached by other
health care institutions with more attractive employee benefits packages and place-
ments. This situation, of competing health care systems, is only going to grow in
future years as our population, national and in Indian communities continue to live
longer and more productive lives.
49
Our scholarship and loan repayment programs offer us the opportunity to attract
highly qualified staff. In fiscal year 2000, 37 new scholarships were awarded to par-
ticipants in two undergraduate scholarship programs in the Health Professions with
46 extensions. Forty-five new awards were made in the Preparatory Pregraduate
scholarship program with 61 extensions, and 60 new awards were made to students
in a health professions graduate programs with 287 extensions.
In fiscal year 1996, the average debt load of a new loan repayment program par-
ticipant was S32,000. In fiscal year 2000, it was $64,000. We anticipate that this
individual debt load will be even higher this year.
Such educational financial assistance, in turn, assures the IHS of a service com-
mitment by the individual who receives such aid. Service payback commitment
can range from 2 to 4 years. Once such commitment is completed, an individual may
have private practice goals or family obligations that preclude their further employ-
ment within the Indian health care system.
Today 62.3 percent of all American Indians and Alaska Natives identified in the
1990 Census reside off-reservation. This figure represents 1.39 million of the 2.24
million American Indian/Alaska Natives identified in the 1990 Census updated by
Indian Health Service. The updated 1994 Census identifies 1.3 million [58 percent]
of the American Indian/Alaska Natives residing in urban areas. For comparison pur-
poses the Indian Health Service total service population is 1.4 million with active
users at 1.2 million. This figure includes 427,100 eligible urban Indian active users
who reside in geographic locations with access to an Indian Health Service or Tribal
facility.
In 1976 Congress passed the Indian Health Care Improvement Act [IHCIA] [Pub-
lic Law 94437]. Title V of the [IHCIA] targeted specific funding for the develop-
ment of supporting health programs for American Indians/Alaska Natives residing
in urban areas. Since passage of this landmark legislation, amendments to title V
have strengthened Urban Indian Health programs [UIHPs] to expand to direct med-
ical services, alcohol services, mental health services, HIV services, and health pro-
motion and disease prevention services. [Public Law 100713, Public Law 101630,
Public Law 102573].
The UIHPs consist of 34 nonprofit 501 (C)(3) programs nationwide funded through
grants and contracts from the Indian Health Service, under title V of IHCIA, Public
Law 94437, as amended. Sixteen [16] of the 34 programs receive Medicaid reim-
bursement as Federally Qualified Health Centers [FQHCs) and others receive fee
for service under Medicaid for allowable services, that is, behavioral services, trans-
portation, et cetera. The other programs are automatically eligible by law but may
not provide all of the necessary primary care service requirements mandated by
FQHC legislation. Over $10 million are generated in other revenue sources.
In the Omnibus Budget Reconciliation Act [OBRA] of 1993, title V of the IHCIA,
and tribal 638 self-governance programs were added to the list of specific programs
automatically eligible as FQHCs. The range of contract and grant funded programs
below are provided in facilities owned or leased by the Urban organizations. Pursu-
ant to title V, the Indian Health Service is required by law to conduct an annual
program review using various-programs standards of Indian Health Service and to
provide technical assistance to the Urban Indian Health Programs.
The range of Indian Health Service/Urban grant and contract programs services
can include: Information, outreach and referral, dental services, comprehensive pri-
mary care services, limited primary care services, community health, substance
abuse [outpatient and inpatient services], behavioral health services, immuniza-
tions, HIV activities, Health Promotion and Disease prevention, and other health
programs funded through other State and Federal, and local resources, for example,
WIC, Social Services, Medicaid, Maternal Child Health.
Sixteen [16] of the 34 programs are certified as Federally Qualified Health Cen-
ters. The other programs are automatically eligible by law but may not provide all
of the necessary primary care service requirements mandated by FQHC legislation.
Today the Indian Health Service provides funding to the 36 [34 title V of the
lHCIA and two demonstration programs] urban Indian health centers and to 10
urban Indian alcohol programs. The urban Indian health programs, range from com-
prehensive primary care centers to referral and information stations. In fiscal year
2001 Congress appropriated $29,843 million for Urban Indian Health. These centers
continue to receive funding as well, from a variety of other Federal, state and pri-
vate sources.
Mr. Chairman, this concludes my prepared statement, I will be happy to respond
to any questions you and other committee members may have.
50
PREPARED STATEMENT OF MICHAEL E. BIRD, PRESIDENT, AMERICAN PUBLIC HEALTH
ASSOCIATION
Mr. Chairman and members of the committee, I am Michael Bird, president of
the American Public Health Association. However, today, I am representing the
Friends of Indian Health, a coalition of over 40 health organizations and individ-
uals. The Friends were formed in 1997 to improve the funding and delivery of
health services to American Indians and Alaska Natives [AVAN].
We thank you for the opportunity to testify today and to comment on health care
personnel issues that we think could be addressed in the Reauthorization of the In-
dian Health Care Improvement Act, S. 212. While the individual members of the
Friends have profession specific concerns we are united on the need to improve the
recruitment and retention of health care providers in the IHS.
A member of the Friends recently sought care from the Phoenix Indian Medical
Center [PIMC]. For a 1 oclock doctors appointment, he left his home at 11 a.m.,
arriving at the PIMC at noon. Having been there before, he knew that he needed
to arrive an hour before his appointment because patients are seen on a first come,
first serve basis . . . even though he had a scheduled appointment. At this facility,
the patient to doctor ratio is overwhelming. Not only does it serve Indian patients
from the Phoenix city limits but also patients from the adjacent reservations that
do not have inpatient services are brought in by vans. The patient was eventually
seen but also told that his back condition had worsened and would probably need
surgery for several herniated discs. However, because of a lack of orthopedists at
the PIMC he was unable to schedule a consultation until September 27. The pa-
tients check up took all afternoon; he returned home at 5 p.m.
This experience is not unique. There is a disparity in access to care throughout
the Indian health care system. For example:
In fiscal year 1998, there were 74 physicians per 100,000 AI/AN beneficiaries,
compared to 242 per 100,000 in the overall U.S. population;
In fiscal year 1998, there were 232 registered nurses per 100,000 AI/AN bene-
ficiaries, compared to 876.2 per 100,000 in the overall U.S. population;
In fiscal year 1998, there were 289 public health nurses in the IHS. This rep-
resents a ratio of 19.8 per 100,000 AVAN beneficiaries;
In fiscal year 2000, there were 21 IHS psychiatrists;
In fiscal year 2000, there were 63 IHS psychologists;
In fiscal year 2001, there were 19 podiatrists to treat the more than 60,000 AI/
AN diagnosed with diabetes;
In fiscal year 2001, there are 11 vacancies for optometrists. Unless these posi-
tions are filled, 27,500 patients will not receive care;
In fiscal year 1998, the dentist to AI/AN beneficiary ratio was 1:2,793 compared
to 1:1,743 for the overall U.S. population; and,
In fiscal year 1999 there were only 20 registered dietitians per 100,000 AI/AN
beneficiaries.
Another way to view this situation is to compare the IHS to the Veterans Admin-
istration. For example, the Carle T. Hayden Veterans Medical Center and the PIMC
are within a mile of each other in central Phoenix. The total number of outpatient
visits at the VA facility was 8,339, compared to 14,400 at the PIMC, a difference
of 6,060. The VA employs 9.5 psychologists, while the PIMC employs 4 psycholo-
gists. The total number of behavioral staff at the VA was 75.5, as compared to the
17 behavioral staff at the PIMC.
While the disparity to access to care is most pronounced in the IHS, it will not
be long before the rest of the country will see similar problems. Various health pro-
fessions are already experiencing or expect to experience shortages in the near fu-
ture. For example:
According to the American Hospital Associations June 2001 TrendWatch,
126,000 nurses are currently needed to fill vacancies at our nations hospitals.
Today, fully 75 percent of all hospital personnel vacancies are for nurses;
According to a study by Dr. Peter Buerhaus and colleagues published in the
Journal of the American Medical Association [June 14, 2000], the United States
will experience a 20-percent shortage in the number of nurses needed in the
United States health care system by the year 2020. This translates into a short-
age of more than 400,000 RNS nationwide;
In the next 20 years, 85,000 dentists will retire and only 81,000 will replace
them;
51
The June 2001 TrendWatch also reports that hospitals have a 21-percent va-
cancy rate for pharmacists; and
Podiatry has experienced a nearly 50 percent reduction in its applicant pool
since the 1990s. In addition, the number of graduates is also dropping. This is
occurring when most States have only 1 to 4 podiatrists per every 100,000 citi-
zens. Federal estimates recommend 6.2 podiatrists per 100,000.
The Friends believes that by improving access to treatment and preventive serv-
ices the IRS will be able to make significant strides in reducing health disparities
and morbidity and mortality rates in the AI/AN population. Evidence of this was
demonstrated by the placement of a full time podiatrist with the Winnebago and
Omaha tribes. During his 4-year tenure, the average annual 16 leg amputations fell
to zero. Not only did this improve the daily living and quality of life for tribal mem-
bers and their families but there was a considerable cost savings also. On the aver-
age, medical and surgical costs associated with leg amputations can average $40,000
a piece. This one podiatrist saved the tribes over $2 million in surgical expenses
during his tenure.
But the IHS needs to move quickly to better recruit and retain health care provid-
ers now. If the Administration waits too long then in the near future when competi-
tion for health care providers throughout the country becomes more intense, the IRS
will not be able to compete for these workers. In order for that to happen, Congress
needs to make it easier for the IHS to recruit health care providers.
Suggested Solutions;
1. Loan Repayment
The most successful recruiting tool that the IHS has is loan repayment. A few
years ago, following recruitment visits to dental schools, the IHS dental branch re-
ceived 100 calls from interested graduating seniors. However, almost every caller
asked about the availability of loan repayment. When they learned that it was mini-
mal, actual applications fell to just over 30. Loan repayment is an excellent recruit-
ing tool. Of the 19 podiatrists serving in the IHS, 13 are receiving loan repayment.
Most health professionals have incurred heavy debt loads during their education.
The average debt load of the 272 people entering the IHS last year was $64,000.
But that figure understates several individual professions:
The average student debt for physicians is $95,000;
The average student debt for optometrists is over $100,000;
The average student debt for dentists is $100,000 [this does not include under-
graduate debts]; and
The average student debt for podiatrists is $110,000.
As part of the Friends fiscal year 2002 appropriations request, we requested that
the IHS loan repayment budget be raised to $34 million. This is an increase of $17
million and would allow the IHS to double its workforce. The IHS could further ex-
tend this funding if Congress were to make these loans tax-free. Under the current
system, Congress not only pays health care providers an annual sum of $20,000 but
also pays an additional 20 percent of that amount for taxes. Therefore, $3.4 million
goes to the Internal Revenue Service. If the loans were tax free, this would allow
the IHS to hire 170 more providers. Just doubling the number of IHS dentists get-
ting loan repayment would mean that 53,000 more dental visits could be scheduled
each year. The Friends recommends that the committee include a provision in S.
212 to make the loans tax-free.
2. Loan Deferment
Under the Higher Education Act, volunteers or members of various health and
Federal programs do not have to repay the principal of, or the interest on, any stu-
dent loan under the Act for 3 years. This includes members of the
Armed Forces,
Peace Corps,
Domestic Volunteer Service,
Full time nurse or medical technicians providing health services, or
Full time employees of a public or private nonprofit child or family service agen-
cy who is providing, or supervising services to high-risk children from low-in-
come communities.
Health care personnel working in the IHS or for tribes are noticeably absent from
this list. Consequently, recent graduates must begin immediate repayment of debt
upon graduation, when their net incomes are at their lowest. For some, that month-
ly payment can be over $1,000. Faced with this burden, many health care profes-
sionals cannot afford to join the IHS, whether as Commissioned Corps, Tribal hires
or urban hires. For those who do take the risk of joining while waiting to be accept-
ed for loan repayment, many soon discover that they cannot make ends meet be-
52
cause of their enormous debt load and leave the IHS to accept more lucrative oppor-
tunities. Therefore, the Friends recommends that the Committee correct this omis-
sion in S. 212 in order to improve the recruitment and retention of IHS health pro-
fessionals.
The need for a robust loan repayment and deferment program is especially critical
when one considers that the IHS pay scale lags far behind the private sector. For
example, in 1998, the average net income among general practice dentists that grad-
uated less than 10 years ago was $141,690, while the newly graduated dentist in
the Commissioned Corps earned slightly more than $50,000. Similarly, the average
annual income for IHS pediatricians is nearly $40,000 less than for pediatricians
in the private practice. This occurs despite the fact that one-third of the AI/AN pop-
ulation is under the age of 15.
3. Housing for Health Care Providers
Another important aspect of recruiting health care personnel is adequate housing.
At some sites, health care providers have reported it is discouraging to have to live
in housing that is worse than college dorms. The American Dental Association re-
ported to Congress, following a 1997-site visit, that a dentist was leaving a remote
site because of the unlivable conditions of her mobile home. No suitable housing
could be found to retain her services. In some areas, health care providers are forced
to live miles away, often in other States, in order to find decent housing for them-
selves and their families. The Friends believes that the IHS needs to assess its staff
quarters and develop a consistent approach to replacing or building new staff quar-
ters. Therefore, the Friends recommends that committee include a study of staff
quarters and a proposal for addressing the situation in S. 212.
4. Exit Interviews:
As the IHS approaches the next decade and must compete for health personnel
with the rest of the country, the Friends believes that it would be very helpful to
require exit interviews of departing employees. Determining whether staff are leav-
ing because of non-competitive salaries, high debt burden, inadequate housing,
spousal needs or a lack of an esprit de corps would be essential to quickly making
corrections to prevent others from leaving. The Friends has heard anecdotal stories
that because of the Government Performance and Results Act [GPRA] that midlevel
support personnel have been lost and paperwork burdens have increased. These
changes directly impact on patient care. They decrease the number of patients that
can be treated and reduce prevention education programs which help to keep down
the level of disease. Health care providers feel overburdened which leads to bum out
and retention problems. For example, the financial resources in the IHS are at 40
percent of that need to provide mental health services. Most Service Units and Trib-
al programs are operated with one or two providers, who provide primarily crisis-
related services with little backup due to the isolated, rural nature of their practice.
Not surprisingly, professional burnout leads to rapid turnover, adversely affecting
the availability of a single backup psychiatrist, let alone the essentials of an ade-
quate, cost-effective mental health program. Maintaining strong patient-provider re-
lationships is essential to good care, but if the provider doesnt stay long enough
to form such a bond, it undermines the care and prognosis of the patient.
Increasing the Use of Students and Volunteers
The IHS employs approximately 500 pharmacists. Many of them joined the IHS
after completing a residency at IHS sites. The pharmacists have 11 IHS sites where
students can do their residencies. Interestingly, new pharmacist hires have a better
retention rate than other health care professionals during the first 5 years of work-
ing for the IHS. While the Friends cannot state for sure that this is due to the stu-
dents early exposure to the IHS we recognize that such a program offers great op-
portunities. We would like to see the IHS work with other professional organizations
and education groups to create similar programs. We believe that this would help
to ease the provider shortage on a short-term basis when the students are at the
sites and possibly in the long run for recruitment efforts.
In addition, the Friends would like to see the IHS explore ways to recruit active
and retiring health care professionals interested in providing care on a part-time or
temporary basis. For example, the American Academy of Pediatrics has received
more than 300 requests from active physicians for information about its Locum
Tenens program, a national initiative that identifies short-term pediatric opportuni-
ties at IHS sites. Additional, we believe that many other providers are not ready
to completely retire and would be willing to volunteer a week, a few days a month
or even 6 months of their services. Their experience and expertise, particularly spe-
cialists like OB/GYNs, psychiatrists, oral surgeons, and orthopedic surgeons are in
high demand. However, in order to make use of these professionals the IHS needs
to create a program where such volunteers can be recruited, enter easily without
a lot of paperwork, provide adequate housing and assure the volunteers that liabil-
53
ity would not be problem. The Friends recommends that the committee include in
S. 212 a pilot project to create such a program in consultation with professional or-
ganizations. Individual members of the Friends would be pleased to work with the
IHS on such a project.
Thank you Mr. Chairman and members of the committee for offering the Friends
of Indian Health the opportunity to testify today on the Indian Health Care Im-
provement Act. We hope we have provided the committee with thoughtful sugges-
tions and we will try to answer any questions you might have.